Dextrose prolotherapy for pain and dysfunction of the TMJ reducible disc displacement: A randomized,double-blind clinical study

To assess the efficacy of dextrose prolotherapy on the clinical signs and symptoms of patients having disc displacement with reduction (DDWR).This prospective, randomized, double-blind clinical study included thirty patients suffering from bilateral DDWR. The patients were randomly divided into two equal groups. After induction of local anesthesia, each joint was injected in two sites; one in the superior joint space and the other in the retrodiscal tissue, using 25% dextrose solution in group I and normal saline in group II. Pain intensity, maximal interincisal opening (MIO), and joint sounds (JS) were evaluated preoperatively, 1 week after each injection, and 3 months and 6 months after the last injection.Patients in group I showed significant improvement in pain and MIO, and higher satisfaction with treatment than patients in group II. Compared to saline injection, dextrose injection resulted in an improvement in JS but without significant difference within and between groups.Intra-articular injection of 25% dextrose is effective in the treatment of pain and dysfunction of TMJ DDWR as shown by significant improvement in pain and MIO and patient satisfaction. The technique is simple, easy to do, safe and should be adopted whenever appropriate.     

Meniscopexy for Internal Derangement of Temporomandibular Joint

The term internal derangement was first adopted to describe any pathologic entity that interfered with the smooth function of the temporomandibular joint (TMJ). The term is currently used exclusively to describe alterations in disc–fossa relations. Internal derangement of the TMJ does not always cause pain, although when the disc becomes displaced, noises and locking can occur and ligamentous, capsular or retrodiscal pain may dominate the clinical picture. Meniscopexy of TMJ was done in ten patients where clinical features suggest true internal derangement of the TMJ refractory to conservative treatment with restricted movement and pain identified as arising primarily from the joint. Magnetic resonance imaging was done to identify the cause of problem.     

关节上腔留注透明质酸钠治疗TMJID的疗效观察

目的 观察颞颌关节内紊乱(TMJID)病例行关节上腔灌洗后留注透明质酸钠的疗效,并与强的松龙作对照。方法 80例颞颌关节内紊乱病例随机分为两组,生理盐水关节上腔灌洗后吸干,分别注入1ml透明质酸钠和强的松龙,术前,术后1周和4周各记录最大开口度,疼痛指数,弹响及饮食习惯。结果 基于上述四项指标的总有效率,术后1周透明质酸钠组为97.5％(39/40),强的松龙组为82.5％(33/40),统计学上有显著差异(P<0.05);术后4周透明质酸钠组为97.5％(39/40),强的松龙组为77.5％(31/40),统计学有非常显著差异(P<0.01)。透明质酸钠组无1例术后疼痛加剧,强的松龙组有70％(24/40)术后1～3天内出现疼痛加重。结论透明质酸钠是一种可替代类固醇,安全而副作用少的关节功能改善剂。     

Clinical signs of temporomandibular joint internal derangement in adults. An epidemiologic study.

This study investigated the frequency and distribution of clinical signs of temporomandibular joint (TMJ) internal derangement in an adult non-TMJ patient population. Four hundred three persons who participated in an epidemiologic investigation were examined for clinical signs of TMJ internal derangement by four examiners who followed a standardized form. Clinical signs of internal derangement were found in 76 persons (19%). Twenty-nine persons (7%) had reciprocal clicking and 47 (12%) had a history of clicking replaced by limitation of mouth opening with deviation to the affected side. Reciprocal clicking was associated with TMJ pain during mouth opening and with limitation of jaw movement. A history of clicking replaced by limitation of mouth opening with deviation to the affected side was associated with pain during mouth opening, limitation of opening, and palpatory tenderness of the TMJ. The study indicates that clinical signs of TMJ internal derangement are present in nearly one fifth of non-TMJ patients. Those with clinical signs of internal derangement frequently also have subjective symptoms but they have not sought treatment for these symptoms.     

Microbiological investigation of retrodiscal tissues from patients with advanced internal derangement of the temporomandibular joint

The aim of this study was to investigate the presence of bacteria in samples of retrodiscal tissues taken from patients suffering from advanced internal derangement of the temporomandibular joint (TMJ). 12 fresh retrodiscal tissue samples were taken from 12 consecutive patients who underwent unilateral TMJ discectomy for advanced TMJ internal derangement (Wilkes stage IV). The retrodiscal tissue samples were stained and cultured for the presence of micro-organisms in microbiology laboratories. No evidence of bacteria or other micro-organisms was found in any of the tissue specimens procured from the TMJ. This study failed to identify the presence of bacteria or other micro-organisms in fresh retrodiscal tissue specimens of the TMJ in patients with advanced TMJ internal derangement.     

Image-guided minimally invasive surgical access to the temporomandibular joint: A preliminary report.

PURPOSE: To establish a protocol for image-guided minimally invasive surgical access to the temporomandibular joint (TMJ). MATERIALS AND METHODS: This study involved 2 patients with TMJ pain and mandibular motion dysfunction. Axial magnetic resonance imaging (MRI) of the TMJ was obtained and loaded into an intra-operative navigation system to guide joint space injection. With a navigated syringe, 1 mL synvisc Hylan G-F 20 was directly injected into the superior and inferior joint spaces under navigation guidance. RESULTS: With the assistance of an intraoperative navigational system, the TMJ MRI images were visualized in 3 dimensions and enabled guiding a needle into the superior and inferior joint spaces for therapeutic injection. The treatment outcome for both patients was satisfactory with improvement in pain score and mandibular motion. CONCLUSIONS: A protocol for image-guided minimally invasive surgical access to the TMJ was established. This could provide the technical basis for evaluation of accurate joint space intervention as a form of treatment of appropriate TMJ disorders.     

Long-term status of TMJ clicking in patients with myofascial pain and dysfunction

This study evaluated the long-term changes in TMJ clicking and general TM disorder symptoms in 190 subjects originally treated by conservative, nonsurgical modalities that were not specifically directed to the problems of TMJ noise or disk derangement. The findings are detailed and support the concept that if the symptoms of pain and dysfunction in patients with clicking can be treated successfully by conservative, nonsurgical modalities, it is generally not necessary to correct the internal derangement with surgery.     

Internal Derangement of Temporomandibular Joint: An Evaluation of Effect of Corticosteroid Injection Compared with Injection of Sodium Hyaluronate after Arthrocentesis

Aims and Objectives

Internal derangements are the commonest disorders of temporomandibular joint (TMJ). Different treatment modalities including conservative and surgical methods have been proposed to treat the same. Arthrocentesis is gaining popularity in the treatment of internal derangement of TMJ. Being minimally invasive it does not have the demerits of surgical approaches and at the same time is producing better results than conservative approaches. This study evaluates and compares corticosteroid and sodium hyaluronate after arthrocentesis in the treatment of internal derangement of TMJ.

Materials and Methods

Sixteen patients with internal derangement were randomly selected and divided into 2 groups (8 in each group). Arthrocentesis of the upper joint space was then performed using Ringer lactate under local anaesthesia followed by injection of either betamethasone or sodium hyaluronate into the joint. Clinical data was collected in the form of pain (visual analog scale), maximum mouth opening, joint sound and deviation before and after treatment up to 6 months.

Results

Both groups of patients were benefited from the treatment at the 6 month follow up and there was slightly less intensity of pain in sodium hyaluronate group compared with corticosteroid group. Maximum mouth opening was also increased in both groups. A decrease in clicking and deviation were seen in both groups. There was no statistically significant difference between betamethasone and sodium hyaluronate.

Conclusion

Intra articular injection of corticosteroid or sodium hyaluronate after arthrocentesis had considerable effect on the TMJ. Both betamethasone and sodium hyaluronate can be used after arthrocentesis with similar results.     

Histological evaluation of the changes in temporomandibular joint capsule and retrodiscal ligaments following autologous blood injection

IntroductionIn recent years injection of autologous blood into the temporomandibular joint (TMJ) has been reintroduced as a treatment of chronic recurrent TMJ dislocation. The effects of this treatment on components of the TMJ is not fully understood. The purpose of this article is to evaluate the effects of autologous blood on TMJ capsule and the retrodiscal ligament.Material and methodsA total of 16 healthy adult country bred pig were used in this study. Autologous blood were injected into the upper joint space (4 ml) and around the capsule of TMJ unilaterally (1 ml). This procedure was then repeated on the opposite side only by using 5 ml of 0.9% saline. TMJ capsules and retrodiscal ligaments were examined four weeks following the injections.ResultsHistological examination of TMJs injected with autologous blood revealed fibrotic changes in 81.25% of the retrodiscal ligaments and 56.25% of the capsular areas. Whilst no changes were seen in the retrodiscal ligaments nor in the capsules of TMJs injected with saline alone.ConclusionThere is little published clinical data on the use of autologous blood injection and as such the mechanism of action is still unclear. The rate of induction of fibrosis within the retrodiscal ligaments in this study were similar to previously reported studies and case series. However, further studies to evaluate the mechanism of this safe and simple technique are needed.     

Arthroscopic assisted release of lateral pterygoid versus scarification of retrodiscal tissue in management of internal derangement of temporomandibular joint-A randomized clinical trial

The purpose of this study was to compare the effectiveness of arthroscopic-assisted lateral pterygoid muscle release versus scarification of retrodiscal tissues in the treatment of temporomandibular joint internal derangement.A prospective, comparative, randomized clinical trial involved 16 patients with TMJ internal derangement. Arthroscopic assisted release of lateral pterygoid muscle was assigned to one group of patients (Group I). Group II patients received arthroscopic assisted scarification of retrodiscal tissues. Data collected through functional examination including visual analogue scale (VAS), maximum mouth opening, lateral excursion, and clicking sound immediately and after 3, 6, and 12 months. Pre- and post-operative MRI was used to assess disc position.The VAS scores decreased in both groups at the end of the follow-up period (0.45 vs 6.75, and 1.13 vs 6.50 in group I and II respectively; P<0.001). The maximum mouth opening improved to 32.9.50 ± 1.69 mm in group I, and 30.49 ± 0.93 in group II (P<0.001). Lateral excursion improved in both groups (P<0.001). Clicking sounds disappeared in all patients.Within the limitations of the study, it seems that arthroscopic assisted release of lateral pterygoid and scarification of retrodiscal tissues may be beneficial in management of anteriorly displaced discs that don't respond to conservative treatments.     

Derangement, osteoarthritis, and rheumatoid arthritis of the temporomandibular joint: implications, diagnosis, and management

Temporomandibular joint (TMJ) dysfunction is often believed to bea young person's malady. However, geriatric patients also present with clinical findings of TMJ clicking, locking, crepitation, limited opening, and pain. With our aging population and the high prevalence of rheumatic and musculoskeletal diseases in the elderly, it is important to understand the etiopathogenesis, clinical presentation, and management of derangement, rheumatoid arthritis, and osteoarthritis of the TMJ. Although arthritis of the TMJ usually causes only mild-to-moderate dysfunction in older patients, they present challenges related to medication use and comorbidity. This article presents the most recent understanding and therapeutic protocols for patient diagnosis and management.     

Effect of bimaxillary orthognathic surgery on dysfunction of the temporomandibular joint: a retrospective study of 500 consecutive cases

We investigated the effect of bimaxillary orthognathic surgery on symptoms in the temporomandibular joint (TMJ) and predictive factors for postoperative dysfunction. A total of 500 patients with different craniofacial deformities who were having bimaxillary orthognathic surgery were assessed for overjet, overbite, maximal mouth opening, maximal protrusion, maximal lateral movement to both sides, and symptoms of TMJ dysfunction (pain on palpation, clicking, or crepitus) before operation and one year postoperatively. The panoramic radiographs taken on the same dates were assessed for reduction in the height of the ramus. Other variables were age, sex, segmentation of the maxilla, and additional genioplasty. Changes in the symptoms of dysfunction were investigated with the McNemar test. Measurements of the maximum mandibular movements taken preoperatively and postoperatively were compared using the paired t test. Multivariate logistic regression was used to assess the influence of the variables on symptoms preoperatively and postoperatively. The effect of occlusal stability (overjet and overbite) on postoperative symptoms in the TMJ was investigated with the unpaired t test. Women and class II patients had significantly more pain on palpation preoperatively, and a significant reduction in pain on palpation and clicking after operation. Predictive factors were preoperative crepitus for postoperative pain, and preoperative clicking for postoperative clicking. Patients with and without symptoms showed no significant differences in overjet and overbite postoperatively. Condylar resorption was found in 29 patients (5.8 %), and only 14 of them had symptoms in the TMJ. In patients with no preoperative symptoms or radiological abnormalities of the condyle, condylar resorption was rare (0.8 %). Orthognathic surgery has a beneficial effect on dysfunction of the TMJ as it reduces pain and clicking considerably. Patients should be informed, however, that TMJ disorders could still develop even if they had no symptoms preoperatively.     

Psychometric profiles and facial pain

The myofacial pain-dysfunction syndrome and atypical facial pain are the most prevalent chronic pain disorders of the facial region. Previously, the myofacial pain-dysfunction syndrome included all TMJ/masticatory muscle pain, jaw dysfunction, and joint clicking. We have segregated two major subgroups subsumed within this diagnostic classification and have assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Significant age and personality differences were uncovered when these subpopulations were compared to subjects with atypical facial pain (AFP). Both MFP and TMJID groups are relatively homologous, involving younger persons than AFP subjects. Alternatively, when MFP, TMJID, and AFP subjects were compared for differences in MMPI psychometric scales, MFP and AFP subjects exhibited significantly higher scores, particularly for hypochondriasis, depression, and hysteria, than did TMJID subjects. It is concluded that subcategorization of myofascial pain-dysfunction patients into a myogenic pain group and a TMJ internal derangement group is justified on the basis of psychometric differences. Furthermore, psychopathologic factors are more significant among MFP and AFP subjects than among TMJID patients.     

Simplified anesthesia blocking of the temporomandibular joint

The general dentist's ability to perform an anesthesia block of the temporomandibular joint (TMJ) can be very beneficial, especially when trying to diagnose or treat patients with temporomandibular dysfunction who have joint and/or muscle pain. There are three common types of internal joint disorders--orthopedic, inflammatory, and degenerative--producing pain in the ligaments, TMJ capsule, or retrodiscal tissues. Secondary muscle splinting also may be involved. Subjects with these disorders can have pain, limited opening, or difficulty with extended opening. Dentists providing care for these individuals may need to schedule longer appointments and deal with mid-treatment facial or TMJ pain as well as more postoperative discomfort. An anesthesia block for the TMJ can reduce pain and protective muscle splinting, increase the mandibular range of motion, and assist in providing a more manageable treatment.     

Incidence of temporomandibular joint symptoms following whiplash injury.

Recently there has been considerable litigation involving the development of temporomandibular joint (TMJ) pain and dysfunction following cervical musculoskeletal injury (whiplash). The purpose of this investigation was to interview, examine, and follow up patients with a diagnosis of whiplash injury to determine the incidence of associated temporomandibular disorders. Patients were divided into two categories: those with and those without radiologic evidence of cervical skeletal injury. In the 63 patients with radiographic evidence of cervical skeletal injury (group 1), none had clicking at the time of initial examination. In the 92 patients without positive radiographs (group 2), only one had clicking. At 1 month follow-up by telephone, 2 of 51 available patients in group 1 had developed clicking, but no new TMJ symptoms were reported by the 78 patients in group 2 contacted by phone. Seventy percent of the initial follow-up group (44 patients) with radiographic evidence of injury were contacted by telephone at 1 year and none reported new symptoms of TMJ pain or clicking. Sixty-five percent of the initial follow-up group without radiographic evidence of injury (60 patients) were interviewed and also reported no new TMJ symptoms. These data indicate that the incidence of TMJ pain and clicking following whiplash injury is extremely low, and that patients who do not have clicking on resolution of their initial pain/dysfunction subsequently do not develop this problem.     

The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders

Because the concept of whiplash as a causative factor for temporomandibular disorders (TMD) is highly controversial, we decided to do a retrospective analysis of patients treated in our office who had sustained whiplash injuries and were treated for cervical and temporomandibular disorders. The records of 300 patients with TMD preceded by a motor vehicle accident were examined retrospectively. The most common presenting symptoms, in order, were: jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe temporomandibular joint (TMJ) clicking. The most common TMD diagnoses were: masseter trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw muscle hyperactivity, and advanced TMJ disk derangement. Based primarily on the physical examination, we concluded that the TMJ and surrounding musculature should be examined similarly to other joints, with no preconceived notion that TMD pathology after whiplash is unlikely.     

Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements.

PURPOSE: This study was designed to investigate the efficacy of arthrocentesis with and without injection of sodium hyaluronate (SH) into the upper joint space in the treatment of temporomandibular joint (TMJ) internal derangements. PATIENTS AND METHODS: Forty-one TMJs in 5 males and 26 females aged 14 to 53 years comprised the study material. The patients' complaints were limited mouth opening, TMJ pain and tenderness, and joint noises during function. Patients were randomly divided into 2 groups in which only arthrocentesis was performed in 1 group and arthrocentesis plus intra-articular injection of sodium hyaluronate was performed in the other group. Both groups contained patients with disc displacement with reduction and with closed lock. Clinical evaluation of the patients was done before the procedure, immediately after the procedure, on postoperative day 1, and at 1, 2, 3, 4, 5, 6, 9, 12, 18, and 24 months postoperatively. Intensity of TMJ pain, jaw function, and clicking sounds in the TMJ were assessed using visual analog scales. Maximal mouth opening and lateral jaw movements also were recorded at each follow-up visit. RESULTS: Both techniques increased maximal mouth opening, lateral movements, and function, while reducing TMJ pain and noise. CONCLUSIONS: Although patients benefitted from both techniques, arthrocentesis with injection of SH seemed to be superior to arthrocentesis alone.     

Temporomandibular joint morphology and disc position in skeletal class III patients

INTRODUCTION: The purpose of this study was to investigate the relationship between temporomandibular joint (TMJ) morphology, including discal tissue and clinical symptoms in class III dentofacial deformity patients. MATERIAL AND METHODS: Forty-four patients were examined with lateral, frontal and axial cephalograms. They were divided into two groups, consisting of a class III symmetry and a class III asymmetry group. By using magnetic resonance imaging the 88 joints could be classified into four types on the basis of disc position and shape: anteriorly displaced disc, anterior type, fully-covered type and posterior type. Furthermore, TMJ morphology was measured tomographically in the sagittal plane. RESULTS: Anteriorly displaced discs in the asymmetry group (56.8%) occurred significantly more frequently than in the symmetry group (18.2%; p <0.05). TMJ symptoms (clicking, crepitus, closed lock, pain) were seen in 17/44 joints (38.6%) of the symmetry and 24/44 joints (54.5%) of the asymmetry group, for a total of 41/88 joints (46.6%). There were no differences in joint space ratio and condyle ratio. However, the fossa ratio on the deviation side was significantly higher than on the nondeviation side in the asymmetry group (p<0.05). CONCLUSION: The incidence of internal derangement in asymmetrical class III patients is higher than in symmetrical mandibular prognathism, and this difference is associated with a difference in TMJ morphology of both sides.     

Comparative study of two treatment methods for internal derangement of the temporomandibular joint

Orthopedic mandibular repositioning and flat plane occlusal splint therapy were compared in the treatment of 20 patients with internal TMJ derangement with reduction. The following conclusions can be drawn. Mandibular repositioning treatment produces significant subjective and objective improvement in the dysfunction of patients with internal joint derangements with reduction. Flat plane occlusal splint treatment produces no significant change in the dysfunction level of patients with internal joint derangements with reduction. Mandibular repositioning treatment may eliminate the reciprocal click of internal joint derangement with reduction. To realize improvement in dysfunction of internal joint derangement, it appears that the reciprocal click must be eliminated. Mandibular repositioning treatment produces a significant improvement in muscle pain associated with internal joint derangement.     

Synovial Chondromatosis of the Temporomandibular Joint: A Case Report and Literature Review

Abstract

Synovial chondromatosis (SC) is a pathologic condition in which mesenchymal tissue rests in a given synovial membrane undergo a metaplastic process, ultimately producing and secreting cartilaginous bodies into the joint space. It is more commonly discussed in the orthopedic literature, since the axial skeleton is the most frequently affected. Although rare, it does occur within the temporomandibular joint (TMJ), with approximately 100 cases previously being described. Within the TMJ, its presentation can be variable, though most cases will show it to be unilateral with fixed and/or loose cartilaginous bodies confined to the superior joint space. Clinically, patients may present with symptoms similar to that of an internal derangement disorder, including pain, clicking, tenderness, functional limitations, and swelling.¹ A thorough history and physical examination, along with proper radiographic examination, are paramount in properly diagnosing SC. Treatment options consist of arthroscopy, arthrotomy with synovectomy, excision of cartilaginous bodies, and possible discectomy.¹ In the current paper, the authors describe the presentation, diagnosis, and surgical management of a SC case involving the right TMJ in a 31-year-old Caucasian female.